Resident Fall Due to Improper Bed Mobility and Bed Positioning
Penalty
Summary
A deficiency occurred when a resident, who required partial to moderate assistance with bed mobility, was rolled in bed by a CNA without ensuring the bed was properly positioned against the wall. The bed had been moved away from the wall to access the call light, and neither the resident nor the CNA realized it had not been returned to its original position. During care, the CNA rolled the resident away from herself, resulting in the resident falling between the bed and the wall, injuring her foot. This incident was the second time x-rays were taken of the resident's foot due to ongoing pain. The resident reported the incident, and it was confirmed through interviews and record review that the bed's position and the method of rolling contributed to the fall. The resident had a history of heart disease, kidney disease, and diabetes, and was cognitively intact according to her most recent MDS assessment. Staff interviews revealed that the CNA did not communicate the details of the fall to the nursing staff, and the incident was only fully understood after the resident described what happened. Facility policy indicated that any fall, regardless of injury, should be reported and managed. The DON confirmed that residents should always be rolled toward the staff member, not away, especially when only one staff member is present.